Abstract

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Introduction
Radiology has been a distinct medical specialty with unique technical challenges from its
inception. The origins of specialisation can be traced back to the technical nature of X-ray image
capture and perhaps more significantly the difficulty of exposing, transporting and developing
images on fragile glass plates for subsequent interpretation. Despite pressure in the early 1900s
to define radiology as a technical service, radiographic image interpretation and reporting
required medically trained specialists. Therefore, radiologists have been clinical specialists, who
have been obliged to also become experts in image capture technology, broad-based advances in
engineering and, more recently, applications of information technology for healthcare, which
continue to drive and be driven by radiology.
Radiology is now the key diagnostic tool for many diseases and has an important role in
monitoring treatment and predicting outcome. It has a number of imaging modalities in its
armamentarium which have differing physical principles of varying complexity. The anatomical
detail and sensitivity of these techniques is now of a high order and the use of imaging for
ultrastructural diagnostics, nanotechnology, functional and quantitative diagnostics and
molecular medicine is steadily increasing. Technological advances in digital imaging have also
enabled the images produced to be post-processed, manipulated and also transmitted rapidly all
over the world to be viewed simultaneously with the transmitting centre.
Radiologists have been strongly involved in these technological developments and have been
responsible for much of the evaluation of the strengths and weaknesses of different
investigations. Radiologists have developed the knowledge of the appropriate integrated imaging
algorithms to maximise clinical effectiveness. They have also been responsible for the
implementation of these developments into the clinical setting and for ensuring the best use of
assets and healthcare resources.
The improved image clarity and tissue differentiation in a number of situations has dramatically
increased the range of diagnostic information and in many cases the demonstration of pathology
without the requirement of invasive tissue sampling (histology). This increased information also
requires careful interpretation without preconception to avoid prejudging the findings. The use of
imaging for functional evaluation and cellular activity has created a new challenge for
radiologists whose training has predominantly been based on the anatomical and pathological
model with limited experience in physiology and cell function. It has therefore been the case that
in some super specialist areas of work, clinician specialists may believe that radiologists have not
contributed sufficiently to the care of patients [1]. It is therefore incumbent on radiologists to
mobilise their skills to utilise these new approaches to evaluate clinical questions in the most
effective way. For this reason the radiological training programme for Europe is now mainly
system- and disease-focussed to ensure that radiologists can respond to the multiple interactions
of patient care.
Although the training programmes are repositioning radiology in this way, these developments
are now occurring and are affecting all radiologists who in general, at present, are satisfied with
their overall position within the respective health care system in most European countries.
Radiologists have no difficulties in finding professionally fulfilling and well-paid employment.
Indeed the rapid rise in workload and complexity of examinations have resulted in a shortage of
radiologists in most countries which may reduce the opportunity or desire to move and up-date
sufficiently with these advances. The availability of high-speed internet transfer of images may
affect the requirement and role of local radiologists by transferring images to major centres for
rapid specialist interpretation. Thus the rapidly developing and expanding field of imaging
becomes a challenge to our specialty, especially as it has also become so attractive to others. We
should therefore be concerned to ensure the future of radiology as a medical specialty and take
into consideration the forces and the dynamics surrounding our profession by meeting them with
foresight and flexibility.
Although as a specialty we must embrace the opportunities that these developments create, the
requirements to embrace all aspects of the speciality are now considered unattainable for any
individual, especially in an environment where the clinicians themselves are focussed on specific
anatomical or disease-related areas as specialists. Therefore the dilemma for radiology and
radiologists is how to achieve the objectives of the specialty and still provide a comprehensive
service within the confines of a radiology department where so many of the tasks previously
undertaken by clinicians are now the province of radiology.

The need for change

Numerous facilities in clinical services are collectively used by different specialties: operating
rooms are not owned by surgeons anymore, ICUs have become independent of departments of
cardiology, internal medicine, or neurology, while emergency rooms are not part of traumatology
departments. Hospital beds are no longer dedicated to individual specialists or specialties and are
available for radiologists for one or two nights following interventional procedures in some
hospitals. At present the radiology department remains predominantly the domain of the
radiologist, but this is changing and there is no specific reason why imaging facilities should not
be used by other clinical specialists trained in imaging, and images produced in these
departments may also be reported remotely.
New knowledge in imaging is being developed at an increasingly rapid rate. The field of
radiology has expanded dramatically. The range of radiology covers diseases from the foetus
through to the multi-morbid aging population, from prostate to the pituitary gland and from
pancreatic neoplasia to bone dysplasia. No single person can master all the available knowledge.
However, the referring physicians need a clinical interface with the imaging specialist. In order
to create added value for the referring clinician, the radiologist must fully understand the clinical
problem. The radiologist is expected to be able to do this at a different level and for all medical
specialties. Therefore clinical experience is required before embarking training in imaging, and
appropriate training in specific clinical specialties may also be needed. If not, imaging may
increasingly be regarded as a sub-entity within the clinical specialty and in that setting each
specialty will take care of its own specialised imaging and training, and the influence of the
radiological expertise would diminish.
Public recognition of the clinical role of radiology is essential and is very much dependent on
contact with the patients [2]. However, over the past years radiologists reading more and more
complex examinations have become less and less visible for patients and the public. Moreover,
in some health care systems the emphasis of radiology work is placed on the in-patient referrals
to major general (secondary) and university (tertiary) hospitals where the role of the radiologist
as part of the team is less obvious to the patient. There has been less focus on the provision of
radiology services to primary care (including general practitioners and office based specialists),
where the requirements are different, with a need for a more general service but still involving a
range of imaging services, and where the individual role of the radiologist is more obvious to the
patient.
In some countries clinical specialists may be the primary providers and interpreters of imaging in
their offices. This has potential disadvantages for the patients. The self-reporting clinician may
focus on the images to confirm or refute a preconceived clinical diagnosis whereas the interface
of a radiologist, reporting the images, provides an independent opinion. It is also suboptimal for
funding healthcare, as self-referral has been shown to increase numbers of radiological
procedures and consequently costs. Moreover, radiologists will ensure the appropriate use of
equipment and quality control, and apply radiation protection principles which are particularly
pertinent with the massive increase in the use of multi-detector CT [3].
Radiology has prospered by staying ahead of the wave of progress. But radiologists will have to
change many of their attitudes and rethink their professional training to accommodate to the
dramatic revolution and evolution of radiology [4]. Radiologists need to adapt to the changes in
technology in order for the profession to deliver the service that patients expect and medical
progress requires.
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Specialisation in radiology
One solution has been a gradual increase in the degree of specialisation of radiologists along
systems and disease-related specialties, which has been strongly advocated by the ESR in its
curriculum. Some radiologists have focussed on particular imaging modalities which may have
assisted the development of these modalities, but the range of imaging techniques to evaluate
particular clinical scenarios is such that this approach is not appropriate when dealing with
clinicians who have all specialised along systems and disease-based pathways. The current
curriculum for training has been adapted to take this process into account. It now separates
radiologists, following training to a core level in all aspects of radiology including all techniques,
into two main categories:

1. Radiologists who have additional dedicated training to provide special interests in two or
possibly three system-based specialties. These radiologists work in teams to provide a
24/7 comprehensive radiological service and at present represent the largest radiological
community.
2. Radiologists who have subsequently focussed on one field of radiology which parallels a
medical or surgical specialty and who work primarily in that subspecialty in secondary or
tertiary referral centres.

It is however still debated how far subspecialisation should proceed and how enthusiastically it
should be promoted. It is also unclear how the process should be managed in order to provide an
integrated cohesive imaging service to the patients and their clinicians.
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Reasons for subspecialisation

The argument for subspecialisation is strong and a number of factors should be taken into
account.

1. Information overload:

Our field has become so complex that no individual can maintain the level of expertise
needed to practice the entire field of radiology. At present we insist that radiologists
become at least minimally competent in the entire field although it is virtually impossible
today to remain a radiologist with competence in all areas of our specialty [5]. However,
in interventional radiology, for example, sub-specialist training is needed to gain deeper
knowledge, new techniques and practical experience to provide a high level of clinical
service. The technical demands for procedural skills and familiarity with new devices
mean that only a few members of a group can develop the expertise to practice
interventional radiology. Mammography quality standards require that physicians
practising mammography interpret a minimum number of cases and attain specific breast-
related continuing medical education to continue the practice.

1. Developments too rapid:

There are many examples of the effect of rapid developments but the increase in the
temporal and spatial resolution of acquisition in CT and the complexities of new software
packages in MR have been paramount. The former has involved radiologists in many
non-invasive vascular imaging interpretations that were previously the domain of the sub-
specialist. The latter has resulted in functional imaging, spectroscopy and diffusion
imaging requiring specialist knowledge to conditions which hitherto have been the
responsibility of the clinical radiologist such as the early evaluation of stroke patients.
The emergence of fusion imaging presents further challenges to staying abreast of this
evolving technology. As the field of radiology expands, the degree of sub-specialisation
requires maintaining competence increases [5]. Thus the growing array of radiological
tools will require radiologists in various practice settings to make fundamental decisions
about how to focus and balance their areas of expertise [6]. It is impossible for the
radiologist, who is providing a busy comprehensive service, to assimilate these advances.

1. Clinicians in secondary and tertiary referral centres are all specialised:

Secondary and tertiary based clinicians have long since abandoned the concept of the
generalist and focus on particular systems or disease-related areas. While the imaging of
disease becomes ever more complex, the clinical conditions remain mainly unchanged
although the ability of the clinical specialist to treat these conditions is advancing. This
reduced pace of change enables the clinicians to assimilate and often develop new ways
of addressing the diseases in their special area, thus posing a challenge to the radiologist
who is not aware of these developments.
 Now better and faster imaging machines enable more accurate diagnosis with less risk
and at lower costs than ever before so that radiologists will not be the only specialty to be
able to identify disease sites and morphology. The developments also apply to clinical
sciences such as the rapid growth of anti-cancer drugs requiring a new insight by imaging
of tumour response, or to developments in laparoscopic surgery which need detailed
staging of disease by radiology.

1. The referring clinician’s role changed by imaging:

The patient characteristics, clinical history and examination remain important to guide the
investigative choices and are an integral part of the clinical examination. Clinical
information is important to correlate with the imaging findings, especially to avoid false
positive imaging diagnoses. However, in many circumstances a long differential
diagnosis may be resolved by modern objective imaging which can provide a precise
diagnosis in a few minutes. The role of surgeons has also been changed by the emergence
of laproscopic surgery and by image-guided endoscopic and interventional techniques.
These developments require even more precise delineation of the lesion before
intervention and yet even closer collaboration between radiologists and referring
clinicians.

1. Patients and clinicians require comprehensive information and the most accurate
diagnosis:

A reduced level of expertise of the non sub-specialised radiologists may reduce the
quality of patient care, and also the respect radiologists are accorded by their colleagues
in other medical disciplines. For example an experienced neurologist or orthopaedic
surgeon is unlikely to rely on a diagnosis made on a MR study by a radiologist who has
had only 3–4 months of training in neuroradiology or musculoskeletal imaging. This lack
of confidence in radiologists would force them to rely on their own interpretations. They
no longer want radiologists to report back with generalised observations about the
abnormalities.

1. Teleradiology can provide instant access to sub-specialist opinion:

Teleradiology is becoming a significant component in the delivery of radiological

services due to the high quality and speed of image transmission. Communication of
images between radiologists, via local or distant networks is now a widely available
option to solicit a specialised opinion in selected cases. This enables subspecialty
opinions to be provided easily and quickly, thus undermining the role of the radiologist
who does not possess a specialised knowledge. The patients and their clinicians are now
rightly expecting an expert opinion and it is possible now to obtain one through
teleradiology services.

1. Technological developments:
 There are often short innovation cycles of radiological equipment and it is important that
there are specialist radiologists who are able to assist the manufacturers with
technological developments and clinical implementation. It is also important to
emphasise that radiologists have special expertise in technology not possessed by other
clinicians, which provide an indispensable link with other disciplines such as physicists,
experts in information technology, molecular biology and engineering. It is essential that
knowledge of the technology used is included in radiological core and subspecialty
training.

1. Research:

It is imperative that radiologists are engaged in research in their own discipline. Research
in radiology is part of the huge domain of clinical research requiring imaging and at
present much of this research is undertaken through multidisciplinary protocols led by
clinicians and scientists with radiologists seen as a relatively small contributor. Unless
specialisation occurs, radiologists will be unable to reverse this situation and thus risk a
further loss of influence in the future of imaging at a time when there is a major
transformation to functional and molecular imaging. The breadth of research topics
relevant to radiology is constantly expanding and includes development in technology
and its applications, epidemiology, molecular biology, computer science and other basic
research fields.

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Reasons for maintaining radiology with special interest(s)

In most secondary care centres and large private radiological offices radiologists have developed
additional expertise in two or three clinical disciplines which supplement the delivery of a
general service and complement each other within the department or practice. This enables the
practice and individual radiologists to add value to the clinicians and provide support to each
other.

1. Diseases are not always restricted to one system:

While a number of disorders may be confined to one organ or system, such as

musculoskeletal or intra-cerebral abnormalities, others may involve a number of systems
such as diabetes, some neoplastic disorders or inflammatory diseases. There may also be
circumstances were the initial patient imaging examination may reveal other
abnormalities, which were unsuspected and potentially life-threatening. A patient, who
may have a specific lesion directly related to the individual specialty, may have co-
morbidity that will affect their management, while other abnormalities and disease
processes can and are demonstrated incidentally by radiology, and the radiologist is
essential to avoid assumptions and also false positive conclusions. In these circumstances
the radiologist needs to have a broad perspective and a wide knowledge of anatomy,
pathology and imaging signs. This is difficult to maintain, even when the initial training
is broad-based, if the subsequent work is highly specialised. It is important that there is
 good joined-up thinking to avoid the patient having unnecessary examinations and being
referred to a variety of physicians.

1. The majority of illness is due to a few common disorders:

Some imaging examinations are commonly performed in most hospitals and all
radiologists should be sufficiently experienced to manage and interpret them.

1. A knowledge of all modalities is important:

The value of different modalities varies by disease and clinical question and some
modalities have considerable limitations in some organ systems. Radiographs, ultrasound,
computed tomography (CT), magnetic resonance (MR) and nuclear medicine techniques
are all of value in different clinical situations in musculoskeletal radiology while in
neuroradiology MR and CT are predominant.

1. Radiology is a 24/7 speciality:

If all radiologists are sub-specialists, it requires a large staff to cover all emergency work
in-house. Sub-specialist staffing requirements are also increased to cover sickness and
leave of absence, if continuity of service is to be achieved. Teleradiology may be of value
but there is a resultant loss of contact between the radiologists and clinicians, if this is
used extensively. The use of this technology is under scrutiny and is being restricted in
some countries to ensure that quality issues are robust. Emergency radiology is now
becoming a specialist area and the presence of radiologists on site in major accident and
emergency departments is essential for the smooth running of the service and although
some local emergency radiology reporting has been replaced by teleradiology.

1. Integrated nature of radiology should not be lost:

If all radiologists are sub-specialists, there may be a loss of unity in the department and a
loss of interest in discussing cases. Satellite organ- or disease-based departments may
become an expectation with a potential duplication and under use of expensive capital
equipment and clinicians may set up their own subspecialty radiology departments in
conjunction with either the sub-specialist radiologist or a clinician who has done some
imaging training as part of their specialist clinical training.

1. Access to subspecialty training is limited in some parts of Europe:

In many countries in Europe sub-specialisation and access to complex equipment is

limited. Therefore no opportunities are available to train or practice in a subspecialty.
This situation is changing by implementing fellowship programmes and by the use of
electronic teaching files and internet-accessible case collections but it may be resource-
limited and the complex sub-specialisation model may not be appropriate outside the
major university hospital setting.
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How should sub-specialisation be implemented in radiological practice?

Subspecialisation is established in university hospital settings and large hospital-based non-
academic practice groups, who are increasingly appreciating the value of having this high level
of expertise within their groups, and the process towards increasing super-specialisation is
already upon us and is continuing. Neuroradiologists focus on spinal, paediatric, interventional,
or head and neck radiology. Interventional radiologists may concentrate on vascular procedures,
non-vascular intervention, or oncologic procedures, such as percutaneous tumour ablation or
chemo-embolisation. Thoracic radiologists are often divided into those who provide cardiac
imaging and those limiting their practice to the lungs and mediastinum.
However the primary care physician will need help from radiologists to decide which imaging
procedure will most likely provide the diagnosis without having to go through the escalating
sequence of imaging or other tests. Radiologists will also be expected to manage and report these
examinations, many of which will cover a spectrum of common disorders which form the
mainstay of any primary care service. To be able to render these consultative services, the
radiologist will need to keep abreast with the new key developments in most subspecialties [1].
It is therefore likely that more than one model of practice will continue, depending on the
physical circumstances of the service required, but in order to be valuable to the clinicians,
the radiologists must have sufficient insight into the clinical problems being investigated
and greater skills in interpreting more complex images than the clinicians themselves. In
areas where there are significant ‘turf strains’, of which there are an increasing number,
subspecialty qualifications may be a requirement. Radiologists should therefore have areas of
subspecialty competence, even if they still provide a broad service most of the time.
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Clinical competence
One of the main reasons why radiologists are losing many turf issues is their inadequate
clinical culture. A high level of technical training is not sufficient for dealing with clinicians
and their clinical queries. Medical practice is becoming increasingly interdisciplinary due to
the vastness of knowledge involved. The importance of clinical training has been emphasised
previously by the ESR but it is still not a requirement for entry into radiology in a number of
European countries. It is essential that, if radiologists are expected to understand the clinical
features and treatment of sub-specialist areas, they have a good clinical base on which to build
that knowledge. Good clinical training will enable radiologists to interact at the appropriate level
with clinicians. Therefore radiologists, to be able to take part in an interdisciplinary discussion as
a key player, will not only have to be specialised in the imaging of a specific organ system but
also to be able to discuss complex clinical cases. Clinicians require radiologists who understand
the clinical questions, keep updated with the most recent advances in the disease processes and
have knowledge of the relevant therapies.
A basic clinical experience and knowledge should be achieved prior to entering radiology. A 1–
2 year programme of clinical work would ensure a sound basic knowledge and give the
appropriate skills for caring for patients and interacting with clinicians. Attempting to develop a
sound clinical base during radiological training may be difficult to organise and will distract and
potentially dilute the radiological training programme. Further subspecialty clinical knowledge
and experience may then be achieved in a number of different ways, which are not mutually
exclusive, including combined clinical and radiological rounds, interdisciplinary meetings,
scientific literature and research and where possible clinical secondments.
As part of this clinical knowledge and experience, radiologists in specialised situations must
have a good understanding of the physiology, pathology, and up-to-date therapies applicable to
their respective organ system. They must also be experts in the multiple imaging modalities
applicable to the clinical problem addressed [1]. Whatever methodology is adopted to develop
the necessary clinical experience, it should be focussed in the area in which a radiologist will
practice, and would be more appropriately embedded in the subspecialty training.
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Interventional radiology
The field of interventional radiology has moved at great speed over the last few years, and there
is no evidence of a reduction in the pace. Indeed quite the opposite is true as more and more
surgical procedures are performed with minimal invasion. Radiology has led the field but is
being overwhelmed by the volume of work and the desire of surgeons and physicians to take
over this work. In order to preserve radiology’s place, it is essential that a radiologist’s training
in interventional radiology is structured in such a way to ensure that they not only have the core
diagnostic imaging skills, knowledge and technical interventional competence, but also have
sufficient clinical skills and training to care for their patients. Interventional radiologists must
also be given the necessary resources of clinic time, hospital facilities and support to take and
treat direct referrals. An innovative approach to training in conjunction with our surgical,
cardiological and oncological colleagues is required to ensure that radiologists remain key
operators in this subspecialty. Interventional radiology should also be funded and recognised for
the clinical work they provide. In health economies that use Diagnostic Related Groups (DRG)
for payment purposes, it is of utmost importance that patients admitted for an interventional
procedure create income for the radiology department in due proportion to the gain provided to
the hospital by the intervention and the hospital stay.
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Training implications
The European Training Charter for Clinical Radiology [7] identifies the first 3 years devoted to
developing the core skills and knowledge in all aspects of diagnostic radiology. The following
2 years may be spent either undertaking subspecialty training or gaining further experience while
developing areas of special interest by focussing more time in two or three organ- or disease-
related specialties.
In a report of the 2005 Intersociety Conference, Reed Dunnick et al. also advocate that the first
3 years of training in radiology could constitute a core curriculum. However, they suggest that
this would be followed by a three-year focused programme. In America, this would replace their
traditional fellowship and could include clinical training. During this period of training each
resident would be required to focus on one or perhaps two subspecialty areas. A variety of
choices would be available depending on an individual’s interest.
There may be organisational challenges to obtaining subsequent clinical experience during
subspecialty training although this could be on the basis of supernumerary status which would
provide clinical exposure without taking clinicians resident positions, but gaining a sound
clinical base prior to starting radiology is entirely possible given the acquiescence of national
policies. Additional clinical experience should follow a structured curriculum individualised for
each subspecialty.
There is a fundamental requirement to increase the exposure of medical students to imaging
taught by radiologists. Presently, the number of radiologists involved in undergraduate training is
low. As a result the potentials and excitement of radiology as a career are not transmitted and the
realisation that radiologists are key players in the patient care pathway is not embedded in the
medical student’s psyche at an early stage. There are a number of initiatives that have been
developed in Europe for increasing the teaching of radiology at undergraduate level and these
should be further promoted.
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Teleradiology: an opportunity
Teleradiology is now an established method of providing radiological services. It is well
developed in the provision of on-call emergency reporting being used by over 70% of
radiological practices in the US both by groups in the US and by Night hawk services around the
world. Teleradiology is also established for the provision of radiological services to remote rural
communities and for sub-specialist opinions and for specialist case transfers. In the UK it is now
used to provide primary reporting services from centres both in Europe and by international
providers.
With the costs of data transmission decreasing as fast as the costs of computing power, practical
opportunities for global teleradiology are rapidly increasing as the cost effectiveness of PACS
and digital radiology increases. In our financially constrained world, the clinical losses
associated with generalised use of teleradiology may be accepted by governments and health
care insurers as a means of cost containment [1].
However, exchanges of information with referring physicians in conferences or reading rooms
are an integral part of delivering a clinical radiological service. It would be a great loss to the
profession if radiologists were to be identified by other physicians and patients only as image
readers sitting exclusively in front of workstation screens and ceasing to be clinicians [1].
The obligation or responsibility or opportunity of a radiologist to go beyond the dictated report
and to offer consultant services to his or her clinical colleagues is what allows the specialty to be
more than a technical service. This will be even more significant as computer-assisted diagnostic
programmes extend to more body parts. If a radiologist provides nothing more than an
observation of abnormal densities, radiology will be minimised or eliminated [8]. Similarly the
role of laboratory medicine was minimised when chemical autoanalyzers provided results
cheaply and accurately and the printed values were significant to the referring physician without
any interpretation or consultation with a laboratory physician.
With so many technological advances it is not surprising that radiology utilisation of high-cost
studies such as CT and MR is expanding rapidly worldwide. This has resulted in a larger and
more complex workload. However the number of radiologists worldwide has not increased at the
same rate as the number of examinations. Radiologists have only been able to manage this
increase by improved workflow and productivity due in part to digital technology. Digital
imaging, workstations, speech recognition technology, PACS and ease of communication via the
internet have all facilitated workflow. Teleradiology may increase productivity in some
circumstances such as night cover in smaller practices and provision of radiology reporting
services to rural communities. It has also been used in some countries to compensate for
manpower shortages and when used in a proactive and controlled fashion may help to avoid
loosing turf to clinical colleagues. It is not however the ultimate solution to manpower problems
which are better resolved by training sufficient radiologists to provide the service within the
locality of the clinicians and patients. Teleradiology must not be allowed to commoditise
imaging services and should only be used to support the comprehensive diagnostic service
provided by radiologists within groups or local area networks.
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Patient relations
Radiological societies maintain (and radiologists do not publicly disagree) that to improve the
public perception of the role radiologists play in patient care, closer contact with patients is
essential [9]
Radiological services are essential to the care of patients. To the patients, however, radiological
services may seem somewhat inconvenient, mysterious or frightening, or may even be a painful
intrusion of their privacy. The perception is further altered by the fact that patients typically do
not choose their radiologist; the referring physician, the health plan or another intermediary
usually makes that choice. Often patients and their diagnostic radiologist never meet. This
situation substantially alters the service bond between them, actually making the relationship
more demanding in a number of ways [10]. Moreover, nurses, technologists and others are
increasingly participating in the performance of imaging examinations. For many patients,
radiologists are identified only with the equipment used and not as physicians who play a vital
role in the decisions that affect them. The use of technologists, nurses, and physician assistants
for intravenous injection of contrast material makes radiologist-patient contact even less
common [2]
Patients believe that the clinician who requested the examination and has received the report is
actually the physician who has interpreted the study [2]. On the other hand, there is widespread
agreement that patients prefer to hear the results of imaging examinations from the radiologist at
the time of the procedure rather than to hear them later from the referring physician, regardless
of the findings [11]. And in another study it has been shown that radiologists and referring
physicians alike tend to support the proposition that, if asked, radiologists should disclose the
results of imaging studies to patients [12].
It seems to be important for the future of the specialty for radiologists to have more contact
with patients in the setting of high-cost, high-impact imaging procedures. The very position
of radiology in a variety of hierarchies ranging from political to economic may depend on
increased recognition by the public of radiologists as physicians. However, results of a
survey by Margulis and Sostman [2] show that more than a half of the injections of contrast
medium in radiological practices are performed by non-physicians. Radiologists are often but by
no means always present in the facility during performance of the study and radiologists rarely
introduce themselves to the patient. Radiologists should always introduce themselves to patients
before any interventional procedure. This is not only good manners but it also establishes the
radiologist’s clinical role in the whole spectrum of planning the treatment and assessing the
prognosis and the response during follow-up.
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Involvement in primary care (general practice (GP) and office based

practice)
Primary care is the point of first patient contact and offers continuous comprehensive and
coordinated care to populations undifferentiated by gender, disease or organ system. In order for
comprehensive care to take place in the primary care setting, the GP often requires access to a
wide range of imaging services. This enables the GP to diagnose and treat the more common
diseases without recourse to hospital services. It also empowers the GP to investigate the patient
more fully so that, if a transfer to a hospital specialist is required, such referral can, in many
cases be for therapeutic care rather than for further investigation.
A GP may wish to work up a patient more fully in conjunction with the clinical radiologist, who
may be a sub-specialist or a radiologist with special interests, so that the requirement for
outpatient referral to specialty services may be avoided or may be a more focussed and
constructive consultation. For such a means of referral to be effective, the radiologist will need to
establish preferred investigation pathways with the clinicians to whom ultimately the patients
may be referred. Finally, the GP may be able to treat a patient directly with the assistance of the
radiologists and some image-guided therapeutic procedures can be undertaken by radiologists
directly for GPs on an outpatient, day-case or short-stay basis.
In the past the workload of departments of radiology was concentrated primarily on supporting
the care of hospital patients and on providing imaging services for outpatients attending
consultant clinics. GPs’ rights to request radiological examinations should be however similar to
those enjoyed by hospital specialists. The concept that expensive investigation should be limited
to clinical specialists is not sustainable. Specialists and GPs should have similar rights to request
examinations. This is particularly highlighted with MRI or CT, where a single examination may
avoid the need for an outpatient visit or an invasive procedure, which would cost considerably
more. If GPs are undertaking primary diagnosis and management of patients, then clinical
radiologists are acting as first-line clinicians and it is entirely reasonable for the radiologist to
undertake the most appropriate examination. The radiologist also possesses the knowledge and
competence to ensure compliance with all aspects of radiation protection and justification of
investigations which is particularly relevant regarding CT. They should therefore recommend
additional examinations where appropriate and manage the imaging diagnostic process in
conjunction with the primary care clinician. The value of investigation which does not show an
abnormality but reduces uncertainty and provides reassurance to the patient and to the GP,
should also not be underestimated by the radiologist [13].
However, radiological investigations available to GPs must be determined by local radiologists
in consultation with their GP colleagues as availability of new, often complex investigations may
be limited in some countries and areas.
Electronic transfer has also developed rapidly over the last few years and the transmission of
images and reports between radiology departments and surrounding GPs is now easily
undertaken.
Closer working relationships with GPs and a stronger involvement of imaging in primary care
will also increase contact of radiologists to their patients and particularly raise public awareness.
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Maximising the use of resources

There has been a tendency in teaching and large regional hospitals for subspecialty services to
pursue the development of satellite departments isolating radiologists from each other. While this
may be essential in some clinical situations such as emergency departments, it potentially
reduces the interaction between sub-specialist radiologists to the detriment of their wider
knowledge and technological development. It may also reinforce the desire for clinicians to set
up their own units and encourages the concept of radiologists working in clinical groups rather
than providing a comprehensive imaging service. Radiologists should work towards a single
strong well-staffed and funded department which is able to accommodate those clinicians who
justifiably need prompt access to expert imaging [3].
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Conclusion
The world of radiology is changing rapidly and radiologists have to be proactive in this process
to survive. The subject is now too broad and complex for an individual to remain a
comprehensive provider. As a result radiologists need to group themselves as specialists in
particular systems or disease-based areas while finding a mechanism to provide a high-quality
service. Radiologists must also be clinicians and understand the clinical features, natural history
and treatments of the diseases that they are requested to investigate. Therefore, if radiologists
want to add value to the chain of healthcare they need to sub-specialise to a greater or lesser
extent according to their working circumstances. Teleradiology services may be appropriate for
small and rural practices as part of an area network especially during nights and weekends and
for interaction with GPs and patients. Radiologists must also interact more directly with patients
and primary care physicians to provide a comprehensive diagnostic and advisory service prior to
the patient entering the secondary care service by managing the investigations of the patients
themselves. This will increase efficiency, clinical effectiveness of the service and speed up the
referral process. Radiologists in the teaching hospitals will also need to specialise to a higher
degree in order to provide a tertiary referral service, communicate and advise clinical experts and
to conduct and drive imaging research as true experts in their field.
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Recommendations
 Sufficient radiologists are in training to ensure that the workforce is large enough to
undertake the workload.
 System- (or disease-) based subspecialisation or the development of system- (or disease-)
based areas of special interest is essential for all radiologists to respond to the complexity
and technological advances of imaging.
 Encouraging radiologists to build strong networks with clinicians. In order to achieve this,
all radiologists should have sufficient clinical knowledge in order to understand the
fundamentals of clinical presentations, natural history, treatment and prognosis of all
common and/or severe diseases. They should also obtain a more in-depth clinical
knowledge of particular diseases related to any subspecialty in which they wish to
practice. This may involve a number of strategies, but subspecialty and special interest
curricula should ensure that trainees participate in clinical rounds, multidisciplinary
meetings and provide opportunities for interaction with relevant clinicians.
 Wide clinical experience should be obtained before entering radiology. In such
circumstances further clinical experience may only be required in a chosen subspecialty
and to a level dependent on previous experience.
 Expanding consulting activities of radiologists with clinical specialists in
multidisciplinary conferences.
 Intensifying relations with GPs offering diagnostic management of their patients
including referral to clinical specialists if needed or full work-up in conjunction with the
GP.
 Communicating with the patient and discussing options particularly in cases of primary
care (patient referred by GP).
 Making use of teleradiology services in a proactive way through local area networks
under the control of radiologists to incorporate general and sub-specialist radiologists in a
comprehensive coverage of clinical scenarios.
 Ensuring that all radiologists involved in such networks keep close contact with referring
physicians through both personal interaction and video conferencing.
 Encouraging radiologists to network with interventional radiologists to learn the basic
aspect of the techniques, indications and imaging follow-up in order to increase the
quality of care to patients and the potential referral to both.
 Ensuring that radiologists are conversant with the technical aspects of the equipment they
are utilising and that sub-specialists involve themselves where possible in the
development and implementation of new innovations.
 Reinforcing the clinical role of radiologists to use resources to increase day-case work, to
make decisions regarding imaging strategies, and to explain the results and further
examinations to the patients.
 Reinforcing the status of the radiologist with special interests.
 Training programmes are always subject to country by country variations but should be
structured with these principles in mind. Possible combinations include:
 System- or disease-oriented sub-specialisation during the last 2 years of residency
training (3+2). This may be followed by an additional 1 year fellowship training where
appropriate.
 Additional clinical experience fitting to the radiological sub-specialisation within the
subspecialty training period and fellowship.
  System- or disease-oriented training in two areas of special interest in the final 2 years of
residency. This may be followed if appropriate by an additional 1 year fellowship training
gaining further experience which may include an understanding of general practice
medicine.

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Acknowledgement
Paper prepared on behalf of the European Society of Radiology by Professor Iain McCall.
Approved by the Executive Council 2009.
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